Treatment of alcoholism among schizophrenic outpatients: 4-year outcomes

Health outcomes and service use patterns associated with co-located outpatient mental health care and alcohol and other drug specialist treatment: A systematic review

ISSUES

Despite long-standing recommendations to integrate mental health care and alcohol and other drug (AOD) treatment, no prior study has synthesised evidence on the impact of physically co-locating these specialist services on health outcomes.

APPROACH

We searched Medline, PsycINFO, Embase, Web of Science and CINAHL for studies examining health outcomes associated with co-located outpatient mental health care and AOD specialist treatment for adults with a dual diagnosis of substance use disorder and mental illness. Due to diversity in study designs, patient populations and outcome measures among the included studies, we conducted a narrative synthesis. Risk of bias was assessed using the MASTER scale.

KEY FINDINGS

Twenty-eight studies met our inclusion criteria. We found provisional evidence that integrated care that includes co-located mental health care and AOD specialist treatment is associated with reductions in substance use and related harms and mental health symptom severity, improved quality of life, decreased emergency department presentations/hospital admissions and reduced health system expenditure. Many studies had a relatively high risk of bias and it was not possible to disaggregate the independent effect of physical co-location from other common aspects of integrated care models such as care coordination and the integration of service processes.

IMPLICATIONS

There are few high-quality, peer-reviewed studies establishing the impact of co-located mental health care and AOD specialist treatment on health outcomes. Further research is required to inform policy, guide implementation and optimise practice.

CONCLUSION

Integrated care that includes the co-location of mental health care and AOD specialist treatment may yield health and economic benefits.

Prevalence and patterns of substance misuse in schizophrenia

Aims and Method

To identify the prevalence and patterns of substance misuse in patients with schizophrenia in a catchment population in Dublin, and to compare this with that of a control group from general practice. Ninety-nine patients and 75 controls were interviewed using a semi-structured technique. Urine samples were obtained from all patients and controls were analysed for illicit substances.

Results

Prevalence of illicit substance and alcohol misuse was similar among patients (illicit substances, 45%; alcohol, 33%) and controls (illicit substances, 43%; alcohol, 25%). Patterns of substance misuse were similar, apart from ecstasy, which was used more commonly by controls. Discrepancies were found between histories of drug use and urinalysis.

Clinical Implications

Illicit substance misuse in patients with schizophrenia may mirror usage in the general population, rates of misuse reflecting cultural factors rather than illness and patterns of misuse reflecting geographical variations in the availability of drugs. A combination of screening methods is more effective than the use of a single source of information.

Substance misuse in a chronic psychosis population Prevalence and staff perceptions

Aims and method

This paper describes the prevalence of substance misuse in a population with chronic psychosis and compares the results with staff estimates. Keyworkers were interviewed using validated questionnaires.

Results

The prevalence rate of substance misuse was higher than in the general population but significantly lower than staff estimates. Staff had little specific training or experience in treating substance misuse.

Clinical implications

Substance misuse is a significant problem among patients with chronic psychosis. Service providers should ensure than staff working with these patients are adequately trained in the management of this problem.

Substance misuse in the severely mentally ill

Comorbidity and dual diagnosis have a fashionable, and thus ephemeral, ring that belies their relevance to day-to-day practice. The topic has been increasingly addressed in North American literature where there is a recognition of the extent of substance misuse in the severely mentally ill, and the need to find ways of effectively managing its consequences. Substance misuse may colour the diagnosis, management and prognosis of major mental illness and can adversely affect the relationship between staff and patients. Despite its common occurrence, it frequently remains undetected (Ananth et al, 1989). With burgeoning research interest, there is some consensus as to how to manage the problem, but, as yet, little agreement on the precise nature of causal relationships.

Longitudinal Course of Clients With Co-occurring Schizophrenia-Spectrum and Substance Use Disorders in Urban Mental Health Centers: A 7-Year Prospective Study

OBJECTIVE

A previous longitudinal study in rural New Hampshire showed that community mental health center clients with co-occurring schizophrenia-spectrum and substance use disorders (SZ/SUD) improved steadily and substantially over 10 years. The current study examined 7 years of prospective clinical and functional outcomes among inner-city Connecticut (CT) community mental health center clients with SZ/SUD.

METHOD

Participants were 150 adults with SZ/SUD, selected for high service needs, in 2 inner-city mental health centers in CT. Initially, all received integrated mental health and substance abuse treatments for at least the first 3 years as part of a clinical trial. Assessments at baseline and yearly over 7 years measured progress toward 6 target clinical and functional outcomes: absence of psychiatric symptoms, remission of substance abuse, independent housing, competitive employment, social contact with non-users of substances, and life satisfaction.

RESULTS

The CT SZ/SUD participants improved significantly on 5 of the 6 main outcomes: absence of psychiatric symptoms (45%-70%), remission of substance use disorders (8%-61%), independent housing (33%-47%), competitive employment (14%-28%), and life satisfaction (35%-53%). Only social contact with nonusers of substances was unimproved (14%-17%).

CONCLUSIONS

Many urban community mental health center clients with SZ/SUD and access to integrated treatment improve significantly on clinical, vocational, residential, and life satisfaction outcomes over time, similar to clients with SZ/SUD in rural areas. Thus, the long-term course for people with SZ/SUD is variable but often quite positive.

PTSD and substance use disorder among veterans: characteristics, service utilization and pharmacotherapy

OBJECTIVE

While there has been considerable concern about veterans with dually diagnosed posttraumatic stress disorder (PTSD) and comorbid substance use disorders, a national study of clinical characteristics, service utilization, and psychotropic medication use of such veterans in Veterans Affairs (VA) has yet to be conducted. We hypothesized that veterans having both PTSD and substance use disorder would have lower socioeconomic status, greater medical and psychiatric comorbidity, higher medical service utilization, and more psychotropic pharmacotherapy fills.

METHODS

National VA data from fiscal year 2012 were used to compare veterans with dually diagnosed PTSD and substance use disorder to veterans with PTSD without substance use disorder on sociodemographic characteristics, psychiatric and medical comorbidities, mental health and medical service utilization, and psychotropic pharmacotherapy. Comparisons were based on bivariate and Poisson regression analyses.

RESULTS

The sample included all 638,451 veterans who received the diagnosis of PTSD in the VA in fiscal year 2012: 498,720 (78.1%) with PTSD alone and 139,731 (21.9%) with dually diagnosed PTSD and a comorbid substance use disorder. Veterans with dual diagnoses were more likely to have been homeless and to have received a VA disability pension. Medical diagnoses that were more strongly associated with veterans with dual diagnosis included seizure disorders, liver disease, and human immunodeficiency virus (HIV). Psychiatric comorbidities that distinguished veterans with dual diagnoses included bipolar disorder and schizophrenia. Veterans with dually diagnosed PTSD and substance use disorder also had a greater likelihood of having had mental health inpatient treatment. There were no substantial differences in other measures of service use or prescription fills for psychotropic medications.

CONCLUSIONS

Several substantial differences were observed, each of which represented more severe medical and psychiatric illness among veterans with dually diagnosed PTSD and substance use disorder compared to those with PTSD alone. However, effective treatments are available for these disorders and special efforts should be made to ensure that veterans with dual diagnoses receive them.

An Intervention for Substance Abuse in Schizophrenia

Substance abuse in schizophrenia is a significant management problem for both clients and treatment agencies, impacting on psychotic symptoms, medication adherence, and participation in training and employment. However, there is little published work on the treatment of drug abuse in this population. This paper describes a cognitive-behavioural intervention for alcohol and cannabis abuse which integrates substance abuse treatment with other aspects of psychosis management.

Implementing Residential Integrated Treatment for Co-occurring Disorders

Objective: Much is now known about effective treatment for co-occurring substance abuse and psychiatric difficulties and many evidence-based practice recommendations have been disseminated. Implementation of these recommended interventions in daily clinical practice has been more of a struggle. This article describes successful implementation of integrated treatment for co-occurring disorders in a small residential program. Methods: A traditional 28-day addiction service was transformed into a 3-month integrated treatment program and 155 individuals with co-occurring disorders agreed to participate in its evaluation. The transformation entailed a completely new manualized service, training in a number of clinical interventions for all program clinicians, ongoing clinical supervision, and formal measurement of clients' backgrounds, substance abuse, quality of life, mental health symptoms, self-esteem, and satisfaction with the program. We also obtained collateral informants' reports on participants' symptoms, substance use, and quality of life. Fidelity to the treatment model was continuously assessed, as were participants' knowledge and skill acquisition. In addition, impact of the implementation on the program clinicians' morale and attitudes toward evidence-based practices was assessed, as was staff turnover and per diem costs. Results: Despite very problematic clinical and sociodemographic histories, the 86 participants who completed the program showed clinically significant mental health symptom improvement, acquisition of knowledge and skill, and high self-esteem and satisfaction with the program. Program fidelity, clinician morale, commitment to the program, and attitudes toward evidence-based practice were uniformly high. These successes were achieved while maintaining the lowest per-inpatient day cost of all hospital inpatient units. Conclusions: The findings support the contention that evidence-based integrated treatment can be implemented with fidelity in regular clinical practice to the benefit of participants, staff, and the hospital. Our experience was that having a scientist-practitioner working as a staff member on the program to lead the implementation was a key element. Future reports will focus on longer-term follow-up of substance use and quality of life outcomes.

Substance use and schizophrenia: adverse correlates in the CATIE study sample

OBJECTIVE

This study examined the relationship between severity of illicit substance use at the time of study entry in a sample of patients diagnosed with schizophrenia and 18-month longitudinal outcomes, including psychopathology, depression, neurocognition, and quality of life.

METHODS

Subjects in the Clinical Antipsychotic Trials of Intervention Effectiveness (N=1432) were divided into three groups according to baseline data: (1) those with moderate/severe drug use, (2) those with mild drug use, and (3) non-users of illicit substances. The groups were compared on other baseline characteristics. Mixed model analysis was used to compare outcomes between the groups using all available outcome data over 18 months, controlling for potential confounding baseline characteristics. Least square means were compared between pairs of groups in the mixed models.

RESULTS

Significantly poorer outcomes were observed in the domains of psychosis, symptoms of depression, and quality of life for moderate/severe drug users in comparison with both mild users and abstainers. No significant differences were found on neurocognitive functioning or days of employment.

CONCLUSIONS

This study suggests that drug use-related impairment co-morbid with schizophrenia may not be a function of use per se but rather, of the severity of use. It highlights the importance of comprehensive assessment and treatment of illicit substance abuse in schizophrenia. Long-term treatment approaches that integrate harm reduction strategies may offer promise in maximizing positive outcomes for such dually diagnosed patients.

Psychosocial treatments for people with co-occurring severe mental illnesses and substance use disorders (dual diagnosis): a review of empirical evidence

Considerable research documents the health consequences of psychosis and co-occurring substance use disorders. Results of randomized controlled trials assessing the effectiveness of psychosocial interventions for persons with dual diagnoses are equivocal but encouraging. Many studies are hampered by small, heterogeneous samples, high attrition rates, short follow-up periods, and unclear description of treatment components. The treatments available for this group of patients (which can be tailored to individual needs) include motivational interviewing, cognitive-behavioral therapy, contingency management, relapse prevention, case management, and skills training. Regardless of whether services follow integrated or parallel models, they should be well coordinated, take a team approach, be multidisciplinary, have specialist-trained personnel (including 24-hour access), include a range of program types, and provide for long-term follow-up. Interventions for substance reduction may need to be further developed and adapted for people with serious mental illnesses. Further quality trials in this area will contribute to the growing body of data of effective interventions.

Treatments for patients with dual diagnosis: a review

BACKGROUND

Comorbid substance use and mental illness is prevalent and often results in serious consequences. However, little is known about the efficacy of treatments for patients with dual diagnosis.

METHODS

This paper reviews both the psychosocial and medication treatments for those diagnosed with a substance-related disorder and one of the following disorders: (a) depression, (b) anxiety disorder, (c) schizophrenia, (d) bipolar disorder, (e) severe mental illness, and (f) nonspecific mental illness. We made no restriction of study design to include all published studies, due to the dearth of studies on treatments of patients with dual diagnosis.

RESULTS

Fifty-nine studies were identified (36 randomized-controlled trials; RCT). Limited number of studies, especially RCTs, have been conducted within each comorbid category. This review did not find treatments that had been replicated and consistently showed clear advantages over comparison condition for both substance-related and other psychiatric outcomes.

CONCLUSIONS

Although no treatment was identified as efficacious for both psychiatric disorders and substance-related disorder, this review finds: (1) existing efficacious treatments for reducing psychiatric symptoms also tend to work in dual-diagnosis patients, (2) existing efficacious treatments for reducing substance use also decrease substance use in dually diagnosed patients, and (3) the efficacy of integrated treatment is still unclear. This review provides a critique of the current state of the literature, identifies the directions for future research on treatment of dual-diagnosis individuals, and calls for urgent attention by researchers and funding agencies to conduct more and more methodologically rigorous research in this area.

Comorbid schizophrenia and substance abuse: a review of epidemiology and course

Over the last dozen years, our knowledge regarding comorbid schizophrenia (SCZ) and substance use disorder (SUD) has evolved in several ways. First, the rate of lifetime comorbid SCZ-SUD appears to have increased another 20-30%, so now about 70-80% of persons with SCZ have lifetime SUD. Second, early remission of SUD has become commonplace among patients with SCZ, perhaps outnumbering the number of SCZ-only patients as well as those with active SCZ-SUD. Third, sustained SUD remission is well demonstrated, though the rates may yet be low. Fourth, research on comorbid SCZ-SUD is filling out our knowledge in many areas, including the characteristics of SCZ patients at risk for SUD, reasons SCZ patients seek out substances, effects of various substances on SCZ course and symptoms, and obstacles to SUD recovery in people with SCZ. The influence of SUD treatment and self-help on epidemiology and course has not been adequately evaluated. Primary prevention and early treatment of SUD in SCZ patients are still relatively neglected, though they offer our greatest hope for enhancing the lives of people with SCZ and improving the cost efficacy of care.

Remission of psychiatric symptoms among drug misusers after drug dependence treatment

The study investigates changes in psychiatric symptoms after drug dependence treatment, and relationships between pretreatment problems, illicit drug use, treatment retention, and changes in psychiatric symptoms. The sample comprised 662 drug-dependent adults recruited at admission to treatment in residential rehabilitation programs (15 agencies) or outpatient methadone treatment (16 methadone maintenance programs and 15 methadone reduction programs). Using a longitudinal, prospective cohort design, data were collected by structured interviews at intake to treatment and at 1-month and 6-month follow-ups. Reductions were found in a range of psychiatric symptoms after admission to drug dependence treatment and among patients treated in outpatient and in residential programs. These reductions occurred rapidly (during the first month) and were maintained at subsequent follow-up. At intake to treatment, 39% of the residential sample met criteria for psychiatric caseness. This figure dropped to 3% at both 1-month and 6-month follow-up. Among methadone patients, 15% met criteria for psychiatric caseness at intake, and this dropped to 5% at 1 month and 3% at 6 months. Improvement in psychiatric symptoms was positively related to treatment retention. Some of the psychiatric symptoms presented by drug-dependent patients at admission to treatment are associated with drug misuse and show rapid remission after substance misuse treatment.

Clinical characteristics and service utilization patterns of clients with schizophrenia-spectrum disorders in public residential detoxification settings

Little is known about the treatment needs of clients found in residential detoxification programs who have comorbid schizophrenia-spectrum and substance use disorders. This study (N = 166) compares the service use patterns of comorbid detoxification clients with schizophrenia-spectrum disorders (CDT-S) to two other client groups: (1) comorbid detoxification clients with other mental health disorders (CDT-O), and (2) comorbid clients in residential mental health facilities with schizophrenia-spectrum disorders (CMH-S). Results show that CDT-S clients were much less likely to receive subsequent mental health treatment than CMH-S clients. Findings indicate that detoxification programs may be important settings in which to identify clients with schizophrenia who have unmet mental health treatment needs.

The associations between substance use disorders, schizophrenia-spectrum disorders, and Axis IV psychosocial problems

BACKGROUND

Substance abuse among individuals with schizophrenia-spectrum disorders (SSDs) is associated with a range of adverse psychosocial outcomes in the areas of occupational functioning, housing stability, economic independence, access to health care, and involvement with the legal system. The aim of this study was to estimate the effects of substance use disorders (SUDs), SSDS, and dual diagnosis with both disorders on the risk for six important Axis IV psychosocial problems. This was accomplished using a large dataset of patients who are representative of individuals in routine US psychiatric practice.

METHOD

Weighted data from the 1999 Study of Psychiatric Patients and Treatments from a practice-based research network of the American Psychiatric Institute for Research and Education were analyzed. Some 615 US psychiatrists provided detailed clinical, psychosocial, and health services information on 1,843 patients, including 285 patients with one or more SUDs without an SSD, 180 patients with a diagnosis of an SSD without substance abuse comorbidity, and 68 dually diagnosed patients. Logistic regression models were used to determine effect estimates (adjusted odds ratios), and corresponding 95% confidence intervals were calculated.

RESULTS

After adjusting for sociodemographic variables and for SSD diagnosis, SUD diagnosis was independently associated with increased risk for five of the Axis IV psychosocial problems of interest (occupational problems, housing problems, economic problems, problems with access to health care services, and problems related to interaction with the legal system/crime) when compared to all other psychiatric patients (n=1,310). After adjusting for the sociodemographic variables and for SUD diagnosis, SSD diagnosis (compared to all other psychiatric diagnoses) was associated with Axis IV economic problems, but not with the other five psychosocial problems of interest. The presence of both an SUD and an SSD diagnosis (dual diagnosis) was associated with a greater risk for four of the six Axis IV psychosocial problems studied, compared to the risks associated with either diagnosis alone. Limiting the substance of abuse to alcohol resulted in similar findings.

CONCLUSIONS

Although SUDs are associated with increased risk for poor social adjustment, the comorbidity of SUDs and SSDs is associated with greatly compounded psychosocial burdens. These findings, from a large sample of representative US psychiatric patients, demonstrate the ongoing need for improved services and policies for those specially burdened patients with the dual diagnosis of both an SSD and substance abuse or dependence.

Changing the world: the design and implementation of comprehensive continuous integrated systems of care for individuals with co-occurring disorders

This article has described the CCISC model and the process of implementation of systemic implementation of co-occurring disorder services enhancements within the context of existing resources. Four projects were described as illustrations of current implementation activities. Clearly, there is need for improved services for these individuals, and increasing recognition of the need for systemic change models that are effective and efficient. The CCISC model has been recognized by SAMHSA as a consensus best practice for system design, and initial efforts at implementation appear to be promising. The existing toolkit may permit a more formal process of data-driven evaluation of system, program, clinician, and client outcomes, to better measure the effectiveness of this approach. Some projects have begun such formal evaluation processes, but more work is needed, not only with individual projects, but also to develop opportunities for multi-system evaluation, as more projects come on line.

Bipolar disorder and substance abuse

Substance use disorders are overrepresented in individuals with bipolar and bipolar spectrum disorders. Although awareness of this phenomenon has increased over the past 20 years, few empirically based treatment strategies have been developed for this challenging patient population. This review examines the relationship between bipolar and substance use disorders and treatment options that have been studied in this patient population. First, we examine the high prevalence rates of substance use disorders in individuals diagnosed with bipolar disorder, the common problems associated with establishing a bipolar disorder diagnosis in individuals who abuse substances, the possible explanations for the frequent coexistence of bipolar and substance use disorders, and the negative effect of substance abuse on the course of and treatment outcomes for bipolar disorder. The review then focuses on treatment approaches for this patient population, including integrated group therapy for co-occurring bipolar and substance use disorders and pharmacotherapies that target both disorders. Finally, we present suggestions for medications that might be tested for their efficacy in treating both disorders in specific subgroups of patients with bipolar and substance use disorders.

[Dual diagnosis of psychosis and addiction. From principles to practice]

The prevalence of comorbidity of psychosis and substance abuse/addiction has been on the rise during the last 10-20 years. Meanwhile, dual diagnosis patients (DD patients) represent a large core group among patients with schizophrenia, and they are difficult to treat. Biological, psychological, and social factors may account for the comorbidity, and the single factors may interact with each other. DD patients tend to have poor compliance and unfavorable outcomes with frequent psychotic relapses and hospitalizations. Efficient treatment models integrate traditional psychiatric therapy and therapy of addiction and modify or adjust the two components to each other. The most successful programs offer integrated treatment for both disorders in one setting. These programs focus on outpatient treatment, they offer pharmacotherapy, motivation therapy, psychoeducation, cognitive-behavioral therapy, and family interventions, and they can achieve significant improvements of social adjustment and decreases of substance use.

Comparing treatments for dual diagnosis: twelve-step and self-management and recovery training

The purpose of this study was to compare the effectiveness of 12-step and cognitive-behavioral (Self-Management and Recovery Training [SMART]) approaches for persons with a dual diagnosis of serious mental illness and substance use disorder in an intensive outpatient/partial hospitalization setting. Participants (n = 112) were alternately assigned to the two treatment conditions, with 50 participants completing the 6-month treatment program. Assessments occurred at baseline, 3 months, and 6 months during treatment, and at 3- and 12-month follow-ups. Analyses were conducted on participants who had completed 3 months of treatment (n = 70). The 12-step intervention was more effective in decreasing alcohol use and increasing social interactions. However, a worsening of medical problems, health status, employment status, and psychiatric hospitalization were associated with the 12-step intervention. SMART was more effective in improving health and employment status, but marijuana use was greater for SMART participants. Improvements in alcohol use and life satisfaction occurred in both approaches. Covariates associated with treatment outcome were identified, with greater attendance being positively related to outcome. Involvement with the criminal justice system was positively related to treatment completion but negatively associated with medical problems. Less alcohol use, fewer medical problems, and better financial well-being at baseline were associated with better attendance.

Longitudinal effects of integrated treatment on alcohol use for persons with serious mental illness and substance use disorders

A randomized experimental design was used to assign participants to an integrated mental health and substance use treatment program or to standard hospital treatment. A multilevel, nonlinear model was used to estimate hospital treatment effects on days of alcohol use for persons with serious mental illness and substance use disorders over 18 months. The integrated treatment program had a significant effect on the rate of alcohol use at 2 months postdischarge, reducing the rate of use by 54%. Motivation for sobriety at hospital discharge, posttreatment self-help attendance, and social support for sobriety were also found to reduce the rate of use during the follow-up period. Implications for mental health treatment and aftercare support are discussed.

Organizing mental health services: an evidence-based approach

BACKGROUND AND AIMS: Health policy makers and program developers seek evidence-based guidance on how to organize and finance mental health services. The Swedish Council on Technology Assessment in Health Care (SBU) commissioned a conceptual framework for thinking about health care services as a medical technology. The following framework was developed, citing empirical research from mental health services research as the case example. FRAMEWORK: Historically, mental health services have focused on the organization and locus of care. Health care settings have been conceptualized as medical technologies, treatments in themselves. For example, the field speaks of an era of "asylum treatment" and "community care". Hospitals and community mental health centers are viewed as treatments with indications and "dosages", such as length of stay criteria. Assessment of mental health services often has focused on organizations and on administrative science. There are two principal perspectives for assessing the contribution of the organization of services on health. One perspective is derived from clinical services research, in which the focus is on the impact of organized treatments (and their most common settings) on health status of individuals. The other perspective is based in service systems research, in which the focus is on the impact of organizational strategies on intermediate service patterns, such as continuity of care or integration, as well as health status. METHODS: Examples of empirical investigations from clinical services research and service systems research are presented to demonstrate potential sources of evidence to support specific decisions for organizing mental health services. RESULTS: Evidence on organizing mental health services may be found in both types of services research. In clinical services research studies, service settings are viewed as treatments (e.g. "partial hospitalization"), some treatments are always embedded in a service matrix (e.g. assertive community treatment), and, where some treatments are organizationally combined (e.g. "integrated treatment" for co-occurring mental disorder and substance abuse), sometimes into a continuum of care. In service system research, integration of services and of the service system are the main focus of investigation. Studies focus on horizontal and vertical integration, primary care or specialty care and local mental health authorities - each of which may be conceptualized as a health care technology with a body of evidence assessing its effectiveness. IMPLICATIONS: A conceptual framework for assessing the organization of services as a health care technology focuses attention on evidence to guide program design and policy development. Mental health services research holds promise for such decision-making guidance.

Cost-effectiveness of mental health services for persons with a dual diagnosis: a literature review and the CCMHCP. The Cost-Effectiveness of Community Mental Health Care for Single and Dually Diagnosed Project

People suffering from comorbid mental illness and substance abuse disorders (the dually diagnosed) are thought to constitute large portions of clients treated as outpatients by public-sector community-based mental health providers. These providers dispense units of ambulatory mental health services and treatments incrementally to maintain clients in the community and out of psychiatric hospitals. Community maintenance is one step, albeit critical, toward quitting drugs and eventual abstinence. Thus, there is a need for information that compares the effectiveness and cost of such services on dually diagnosed clients to identify appropriate low-cost high-yield treatment and service options and packages. This article provides a review of the literature on the effectiveness of ambulatory mental health services and recent emergent reports of cost-effectiveness of programs for the dually diagnosed, paying special attention to the gray areas and gaps. This article also describes a new project; an inexpensive add-on to an existing community mental health center. The project will be examining over 4 years of data to compare influence and cost of different ambulatory mental health services and treatments delivered to a matched pair group of clients with dual disorders and those with only mental illness. The intention of this project is not only to address gray areas and gaps in the literature, but also to inform a more rational deployment of mental health services.

The state hospital and the community: an essential continuum for persons with severe and persistent mental illness

Assertive Community Treatment and related approaches will have a defining impact on state hospitals, now and in the future.

Achieving effective treatment of patients with chronic psychotic illness and comorbid substance dependence

OBJECTIVE

The changing effectiveness of a treatment program for dual-diagnosis patients was evaluated over a 2-year period with the use of a sequential study group design.

METHOD

The treatment outcome of 179 consecutively enrolled patients with chronic psychotic illness and comorbid substance dependence who entered a specialized day hospital dual-diagnosis treatment program from Sept. 1, 1994, to Aug. 31, 1996, was evaluated. The 24 months were divided into four successive 6-month periods for comparing the evolving effectiveness of the program for groups of patients entering the day hospital during these four periods. Treatment attendance, hospital utilization, and twice weekly urine toxicology analyses were used as outcome measures.

RESULTS

The initial treatment engagement rate, defined as at least 2 days of attendance in the first month, increased significantly from group 1 to group 4, more than doubling. Thirty-day and 90-day treatment retention rates also substantially increased from group 1 to group 4. More patients had no hospitalization in the 6 months after entering the day hospital program than in the 6 months before entering the day hospital program. Urine toxicology monitoring indicated that the patients in group 4 were more likely than those in group 1 to remain abstinent at follow-up.

CONCLUSIONS

The evolving clinical effectiveness of a developing program can be quantified by using a sequential group comparison design. The sequential outcome improvements may be related to the incremental contributions of assertive case management and skills training for relapse prevention.

Attitudes towards alcoholics anonymous by dually diagnosed psychiatric inpatients

Self-help programs such as Alcoholics Anonymous (AA) have been viewed as beneficial adjuncts to comprehensive treatment programs for the treatment of alcohol use disorders. The usefulness of such programs for individuals with dual psychiatric disorders has not been established. This study examined the alcohol and psychiatric treatment histories of 60 psychiatric inpatients with concomitant alcohol use or abuse with attention to the frequency and correlates with past AA attendance. Most subjects reported feeling comfortable with the basic tenets of AA; neither diagnosis nor gender was related to AA participation, belief in its basic tenets, or willingness to attend AA in the future. Regular, past attendance at AA was surprisingly high (37%) and was not different for individuals with schizophrenic spectrum disorders compared to those with other psychiatric disorders. The majority reported plans to attend AA as part of their outpatient treatment program. The potential benefits of AA for dual diagnosis individuals deserve further attention.

Economic impacts of assertive community treatment: a review of the literature

BACKGROUND

Assertive community treatment (ACT) is an extensively studied and widely imitated community support treatment model for severely mentally ill individuals. Several previous reviews have documented its favourable effects on clients and their families. This is the first review to focus on economic outcomes.

METHODS

Nineteen randomized studies and 15 nonrandomized studies describing ACT programs were identified based on 2 criteria: 1) provision of services primarily in the community and 2) shared caseloads. Percentage reduction in hospital days was calculated for the 34 study sites where reported data allowed it. Multiple-regression methods were used to relate reduction in hospital days to program fidelity and other contextual factors. The impacts of ACT on emergency-room use, use of outpatient services, housing, costs, and other economic outcomes were also examined.

RESULTS

Higher-fidelity programs appear to reduce hospital days by about 23 percentage points more than lower-fidelity programs (95% CI = -41.2, -5.2). The estimated regression coefficients imply that a high-fidelity program reduces hospitalizations by about 58% over 1 year if the alternative involves some type of case management and by 78% if it does not. ACT appears to increase the proportion of clients who live in independent housing situations, but the effect on use of supervised housing, and therefore on housing costs, is ambiguous. The effects on use of most other resources are inconsistent across studies. Overall, ACT appears to result in somewhat lower costs, whatever the perspective of analysis adopted.

CONCLUSIONS

The most reliable cost offset to ACT treatment costs appears to be reduced hospital use. Using Quebec costs, an ACT program must enroll people with prior hospital use of about 50 days yearly, on average, to break even. As care systems evolve to reduce their reliance on hospitalization as a care modality with or without ACT, this threshold will become increasingly difficult to achieve. The primary justification for implementing ACT services will then become their clinical benefits.

Exploring the diversity of dual diagnosis: utility of cluster analysis for program planning

This study demonstrates the utility of using cluster analysis to explore the heterogeneity of dual diagnosis populations so as to facilitate planning and implementation of individualized treatment programs. A sample of 467 persons admitted to a state psychiatric hospital with DSM-III-R psychiatric diagnoses and substance abuse problems were interviewed on the Addiction Severity Index (ASI) and other measures to assess psychological, social, and community functioning. Scores on seven ASI severity ratings (medical, employment, alcohol, drug, legal, family, and psychiatric functioning) were used to group patients into seven homogeneous subgroups using cluster analysis: best functioning, unhealthy alcohol abuse, functioning alcohol abuse, drug abuse, functioning polyabuse, criminal polyabuse, and unhealthy polyabuse. Cluster reliability and validity were demonstrated using split-half tests as well as cross-sectional and longitudinal analyses. Results illustrate the extreme heterogeneity of dual diagnosis and are suggestive of how individualized treatment programs can be matched to the particular needs of patients with dual diagnoses.

Toward cost-effective care for persons with dual diagnoses

Implementing services that control costs and improve client functioning for persons with both severe psychiatric and substance disorders is paramount in a managed care environment. In this clinical trial, standard mental health care augmented by the behavioral skills intervention was more effective than two other approaches (case management and modified 12-step recovery) in interventions with persons with dual diagnoses across indicators of psychosocial adjustment, psychiatric and substance abuse symptoms, and mental health service costs. These findings reinforce the need to address mental health and substance disorders concomitantly; to provide skill-building interventions as the primary ingredient of active treatment to address various instrumental, coping, and social skill deficits that clients with dual diagnoses have; and to monitor the effectiveness of the services and client progress every six months on multiple adjustment and symptomatology dimensions.

Methodological and clinical challenges in evaluating treatment outcome of substance-related disorders and comorbidity

OBJECTIVE

To review the steps required to develop an outcome evaluation package and to report on the 12-month outcome of an integrated day program.

METHOD

Based on the identification of salient outcome predictors, standardized instruments were selected. A cohort of 78 patients was assessed at the time of admission to the program, at discharge, and 3, 6, and 12 months afterward.

RESULTS

Improvements were sustained over 1 year in all areas including treatment needs, quality of life, and readiness to change.

CONCLUSIONS

The gap between the "cultures" of treatment and research must be narrowed. Following evidence of a program's general effectiveness through outcome monitoring, a randomized control design is optimal for specific interventions. The optimal length of follow-up depends on the perceived confounds.

Using measures of readiness to change in individuals with schizophrenia

The literature suggests that substance abuse treatment for schizophrenia patients should consider both the patients' readiness for active treatment and matching phases of intervention with phases of the patient's acceptance of his or her dual problems. This study assessed the suitability of existing measures of "readiness to change" for use with individuals with schizophrenia. Outpatients (n = 39) with a diagnosis of schizophrenia and alcohol and/or drug dependency or abuse were given three measures to assess the stage of readiness to change. Results suggested that there was no agreement between stages defined by the interviewer and stages defined by self-report. This has implications for assessing readiness to change in terms of substance use in a population with schizophrenia.

A relapse prevention group for patients with bipolar and substance use disorders

Although bipolar disorder is the Axis I disorder associated with the highest risk of having a coexisting substance use disorder, no specific treatment approaches for this dually diagnosed patient population have thus far been developed. This paper describes a 20-session relapse prevention group therapy that the authors have developed for the treatment of patients with coexisting bipolar disorder and substance use disorder. The treatment uses an integrated approach by discussing topics that are relevant to both disorders and by highlighting common aspects of recovery from and relapse to each disorder.

Substance abuse and psychiatric illness: treatment experience

The purpose of this paper is to describe an outpatient dual-diagnosis treatment program and 1-year clinical outcome and hospital utilization data. Subjects were 118 consecutive admissions to the Seattle Veterans Affairs (VA) Medical Center's Dual Disorders program over the period from June 1, 1992, to August 31, 1994. Program eligibility requirements included having a current substance use disorder and an active non-substance-related major Axis I disorder (typically major depression, post-traumatic stress disorder [PTSD], bipolar disorder, or schizoaffective disorder). The treatment frame involved group-based programming (including support, medications management, and psychoeducation), routine urine drug screening, and crisis interventions. Results showed that subjects averaged 1.5 non-substance-related Axis I psychiatric disorders (54% involving psychotic symptoms) and 1.8 active substance use disorders. Patients stayed engaged in treatment for a median of 217 days, with 60% of patients having no positive drug screens, and the overall sample having a 40% reduction in the number of inpatient bed days in the year after intake. Conclusions were that, for a number of patients with comorbid disorders, psychiatric stabilization and cessation of substance use can be accomplished within an outpatient treatment frame that averages two completed clinical contacts per week.

A review of comorbidity: major mental illness and problematic substance use

OBJECTIVE

The aim of this paper is to critically review the literature on major mental illness and problematic substance use in order to provide clinicians and policy-makers with evidence to support proposed directions for management of the above.

METHOD

The available literature was accessed using computerised databases and manual searching.

RESULTS

The predominantly North American-based literature is largely descriptive. Those studies which attempt empirical evaluation are limited by methodological weaknesses which include small sample sizes, short follow-up periods, inadequate measurement of substance use, lack of experimental design, and treatment drift over time. However, there is consensus among most studies regarding prevalence rates and treatment.

CONCLUSIONS

Problematic substance use is the most common comorbid condition among people with a major mental illness and is associated with poorer patient outcomes. There is evidence to suggest that the integration of mental health and drug and alcohol services will result in improved detection, assessment and management of comorbidity. Integration refers to the provision of comprehensive services by a single service with staff who are competent in both mental health and drug and alcohol skills. A tolerant, non-confrontational approach to substance use is most appropriate for people with a major mental illness. Treatment programs need to recognise the longitudinal nature of substance abuse and dependence. More research needs to be conducted in this field in order to establish guidelines for effective management.

Group treatment for substance abuse in schizophrenia

OBJECTIVES

A review of the relevant research suggests a need to develop an appropriate, effective, and replicable treatment to help individuals with schizophrenia and substance abuse problems. This pilot study describes a biweekly group specifically designed to help the individual with both schizophrenia and substance abuse. The components of the group were support, psychoeducation, and skills training. Attention was also paid to the stage of recovery.

METHOD

Eighteen subjects attended the group and were assessed pregroup. Thirteen subjects completed a 1-year follow-up, and 5 subjects were assessed between 3 and 6 months.

RESULTS

At the follow-up assessment, 8 subjects (44%) were abstinent.

CONCLUSIONS

This type of treatment appears to be effective for reducing substance abuse in this population.

Long-term patterns of service use and cost among patients with both psychiatric and substance abuse disorders

OBJECTIVES

This is a longitudinal study designed to determine: (1) if patients dually diagnosed with psychiatric and substance abuse disorders incur higher health care costs than other psychiatric patients and (2) if higher costs can be attributed to particular subgroups of the dually diagnosed or types of care.

METHODS

Two cohorts of veterans treated in Veterans Affairs mental health programs at the start of fiscal year 1991 were followed for 6 years: one cohort of inpatients (n = 9,813) and the other of outpatients (n = 58,001). Data were analyzed on utilization of all types of Veterans Affairs health care. Repeated measures analysis of variance was used to examine cost differentials between dually diagnosed patients and other patients.

RESULTS

Dually diagnosed outpatients incurred consistently higher health care costs than other psychiatric outpatients, attributable to higher rates of inpatient psychiatric and substance abuse care; however, this difference decreased with time. Costs were substantially higher in the inpatient cohort overall, but there were no differences in cost between dually diagnosed and other patients.

CONCLUSIONS

In an atmosphere of cost cutting and moves toward outpatient care, the dually diagnosed may lose access to needed mental health services. Possibilities of developing more intensive outpatient services for these patients should be explored.

Treatment models for clients with co-occurring addictive and mental disorders

Recent epidemiologic studies conducted by the National Comorbidity Survey have indicated that up to 51% of individuals with a serious mental illness are also dependent on or addicted to illicit drugs. However, only 50% of these clients with cooccurring addictive and mental disorders receive treatment that addresses both issues. The author provides a historical overview of treatment philosophies and approaches, describes current treatment models, and reports on outcome data that describe the efficacy of current treatment. Recommendations are made for nurses to incorporate effective treatment models into nursing practice.

A model for dual disorder treatment in acute psychiatry in a VA population

One model for addressing the dual disorders of substance abuse and a concomitant mental disorder in an acute-psychiatry inpatient ward of a VA Medical Center utilized psychoeducation and ward policies to empower patients to make decisions affecting their recoveries. Existing staff shared responsibilities for implementing activities and creating ward milieu that supported psychiatric patients toward a life free of alcohol and drugs as they gained in acceptance of responsibility for the management of their mental disorders. Integrated programming assisted patients in constructing a meaningful path of recovery out of multiple treatment approaches and philosophies. Treatment principles, ward policies, and goals for an integrated acute-psychiatry model evolved over 4 years. Designed from a consumer-oriented "strengths perspective," patients responded to the new programming with satisfaction and gratitude. Recent adaptation of these policies, principles, and goals to a newly instituted continuous-care treatment program indicates the appropriateness of their application for outpatient dual disorder treatment and programming as well.

Detecting comorbid substance misuse among people with schizophrenia in the community: a study comparing the results of questionnaires with analysis of hair and urine

Substance misuse among people with schizophrenia is thought to be common and to adversely affect the outcome of the illness. The shortcomings of studies in this area include patient samples that are not epidemiologically-based, and methods for detecting substance misuse that have serious limitations. We investigated the frequency and severity of substance misuse among people with schizophrenia living in the community in London. Interviews were conducted with a community-based sample of 39 people with schizophrenia aged 35 years or less, living in Inner London. The assessments included ratings of psychopathology, movement disorders and substance misuse, and co-informant histories. Urine and hair specimens were analysed for a range of substances. Urine samples were collected from 37 patients and hair samples were provided by 36 patients. Comorbid substance misuse was reported or detected in 63% of the sample. The information elicited using a structured questionnaire for both informants and subjects represented an under-estimate of psychostimulant misuse and opiate misuse compared with the results obtained by hair or urine analysis. Hair analysis revealed that 12 (33%) of those patients providing samples had covertly abused amphetamines, opiates or cocaine in the previous 3 months. The study demonstrated that hair analysis is a well-tolerated, sensitive test for substance misuse. The technique has several advantages over questionnaires and urine analysis for clinical and research purposes. Further applications include the assessment of comorbid substance use in particular groups of patients with schizophrenia, such as during first-episode or psychotic relapse, or those with forensic problems or apparent resistance to treatment.

Integrated treatment for dually diagnosed homeless adults

This study examined the effects of integrating mental health, substance abuse, and housing interventions for homeless persons with co-occurring severe mental illness and substance use disorder. With the use of a quasi-experimental design, integrated treatment was compared with standard treatment for 217 homeless, dually diagnosed adults over an 18-month period. The integrated treatment group had fewer institutional days and more days in stable housing, made more progress toward recovery from substance abuse, and showed greater improvement of alcohol use disorders than the standard treatment group. Abuse of drugs other than alcohol (primarily cocaine) improved similarly for both groups. Secondary outcomes, such as psychiatric symptoms, functional status, and quality of life, also improved for both groups, with minimal group differences favoring integrated treatment.

Impact of assertive community treatment on homeless persons with co-occurring severe psychiatric and substance use disorders

This study evaluated the impact of an integrated (mental health/substance abuse) assertive community treatment program on homeless persons with serious mental and substance use disorders. High rates of retention in treatment, housing stability, and community tenure were attained, and all but the most severe substance users appeared to gain these benefits. While the intervention appears to be an effective means of retaining in services and monitoring such difficult-to-treat and costly populations, it did not yield high rates of abstinence and social benefits in severe users.